Claims related to this care are considered authorized care. In both SAS and SQL data, outpatient data are organized in long format, with one record per CPT code. In some cases, there is a one-to-one relationship between VEN13N and MDCAREID. The SAS PHARVEN dataset contains information only about pharmacy vendors. SAS data are housed in 8 ready-to-use datasets per fiscal year. FBCS is moving to a centralized system in the near future, where there will be centralized rules and national policies with 3 distinct groups: CCN (network), CCRA (authorization), and CCRS (reimbursement system; an IBM product). Current Decision Matrix (10/21/2022) The 2 sets of DRGs are not interchangeable. Many veterans now have access to Non-VA medical care through the new Veterans Access, Choice, and Accountability Act (VACAA, or Choice Act). Fee Basis: 214-857-1397 C & P. VA Claims Representation; RESOURCES. Appendices G and H, copied from the Non-VA Medical Care program website, describes in detail the types of records for which each Fee Purpose of Visit (FPOV) codes are assigned. [FeeServiceProvided] table. SQL inpatient data contain up to 5 diagnoses and 5 procedure codes, while SAS inpatient data contain up to 25 diagnosis codes and up to 25 procedure codes. There are delays in the processing of Fee Basis claims. Four FPOV (Fee Purpose of Visit) codes can be used to identify payment for unauthorized claims. The Implementer of this technology has the responsibility to ensure the version deployed is 508-compliant. SQL Fee Basis data are stored in the form of multiple relational tables that must be linked, or in SQL parlance, joined, in order to create an analysis dataset. On March 17, 2022, The U.S. Court of Appeals for the Federal Circuit issued a ruling that changes VA's ability to reimburse as secondary payer under 38 U.S.C.1725. It is not available for claims in which payment was based on a contract amount. Data Quality Program. The Department of Veterans Affairs (VA) often pays providers in the community to provide care to Veterans when it is unable to provide such care itself (e.g., due to a lack of resources or delays in providing care), or when it is infeasible to do so (e.g., emergency care). The process of linking can be complex; analysts should take care to reduce errors during this process. SAS and SQL data are organized differently and contain different variables. [FeeInpatInvoice] table, one must first link that table to the [Fee]. The National Provider Identifier (NPI) is a unique 10-digit identification number issued by the Centers for Medicare and Medicaid Services to all health care providers in the United States. Payment guidelines for non-VA are outlined in federal regulations 17.55 and 17.56. There may be many providers that use the same vendor for billing. If disbursed amount is missing (but not $0), use payment amount instead. Electronic Data Interchange (EDI): Payer ID for medical claims is 12115. Fee Basis providers vary in how frequently they submit an invoice for Fee Basis care. Payments received from a Veterans private health insurance carrier are credited towards any applicable VA copayments, reducing all or part of the Veterans out-of-pocket expenses. Among non-missing observations, HERC analyses found a many-to-many relationship among NPI and VEN13N. VIReC. visit VeteransCrisisLine.net for more resources. In SAS, the outpatient data are housed in the MED files. For more details, including rules for handling patients transferred during a stay, see federal regulation 38 CFR 17.55. For care received under the Choice Act, Veterans will work with the third party administrators of the Choice program to find an eligible provider in their area.4. Use Azure Rights Management Services (Azure RMS) for encrypted email. Beware of VISNS 4, 15, and 23, as they have their own integrated system. In some cases it may appear that single encounters have duplicate payments. In SAS data, there is also a primary service area variable (HOMEPSA) that indicates the station to which the Veterans residence is assigned based on geography. Detailed information about accessing each of these data sources is available at the VHA Data Portal (VA intranet only: http://vaww.vhadataportal.med.va.gov).See Table 10 for a summary of the data sources. Researchers and analysts will have to take care to collapse observations properly if warranted, for example to determine the costs, procedures or diagnosis associated with a single stay or visit. However, investigation has confirmed these are partial payments made for a single encounter or procedure. U.S. Department of Veterans Affairs. If a researcher decides to use FPOV, please note that an FPOV value of 52 indicates ED visit for persons whose care is covered under the Millennium Bill and should thus be included in evaluating ED care. Attention A T users. There are two important variables to consider if evaluating the cost (VA reimbursement) of Fee Basis Care: the payment amount (AMOUNT in SAS, PaidAmount in SQL) or the Financial Management System (FMS) disbursed amount (DISAMT in SAS, DisbursedAmount in SQL). National Non-VA Medical Care Program Office (NNPO). Some VA medical centers purchase care from only one of the hospitals in the chain. U.S. Department of Veterans Affairs. The discussion below pertains to both SAS and SQL data. [XXX] tables, but also the [DIM]. Veterans Access, Choice, and Accountability Act of 2014 (VACAA): The Choice Program and the Choice Card [presentation]. Community provider mails the paper claims and documentation to the new mailing address of VA's central claims intake location. one episode of care, which can have multiple dates within the prescribed treatment, one provider, as identified by the Tax Identification Number (TIN), and. The Medicare hospital provider ID (MDCAREID) is entered by fee basis staff in order to calculate hospital reimbursement using the Medicare Pricer software. Most importantly, they do not represent all care provided during the fiscal year. The FMS disbursed amount is the payment amount plus any interest payment. Last updated August 21, 2017 Previously, VA could reimburse Veterans or pay non-VA hospitals directly only if a Veteran has no other health insurance. Thus, researchers using later years of data should be aware that files are not static and will continue to be updated. INTIND and INTAMT are not always concordant. [OEFOIFService]and [Dim].[POWLocation]. National Institute of Standards and Technology (NIST) standards. VA intranet only: http://vaww.vhadataportal.med.va.gov/Resources/DataReports.aspx). PatientIEN is assigned by the facility. VA Form 10-583, Claim for Payment of Cost of Unauthorized Medical Services. The vendor no longer supports VA installations of this technology. The VendorType contains information about whether the service was provided by a laboratory, radiology, physician, pharmacy, other, travel, prosthetics, federal hospital, public hospital or private hospital. There are two types of keys: primary keys and foreign keys. This improves claim accuracy and reduces the amount of time it takes for us to process claim determinations. If the gap is 0 or 1, it is part of the same hospital stay and we then want to assess its discharge date. Our review of the data suggests that pharmacy and ancillary claims take longer to process than inpatient or outpatient claims. If the Veteran went to the ED and was not admitted to the hospital, this would be considered outpatient care. Veterans Health Administration. With the exception of supplying remittance advice supporting documentation for timely filing purposes, these processes do not apply to authorized care. Accesed October 16, 2015. For example, if the Veteran had an Emergency Department (ED) visit and then was admitted to the hospital, this would be considered inpatient care. Last updated validated on Tuesday, January 3, 2023 SAS versus SQL data differ in three main ways: Appendix A lists all variables in the SAS files. PO BOX 4444. VA Fee Basis Programs. As part of the process, claims and supporting documentation are scanned for compliance prior to conversion to electronic format. The SQL prescription data are housed in the [Fee]. To enter and activate the submenu links, hit the down arrow. Other work by HERC researchers indicates that in the FY 2014 data, DXLSF and DX1 were identical 47% of the time. The Medicare Ambulance Fee Schedule consists of a base rate plus mileage. This section describes two elements of the program: the range of services covered and the payment rules used to determine the amount that VA will pay (DISAMT). Before working with any SQL tables in CDW, we recommended familiarizing yourself with the schema diagram in order to understand how to link tables to one another. In SAS, the Patient ID will be the SCRSSN and the admit date is the treatment from date. access; blocking; tracking; disclosing to authorized personnel; or any other authorized Our office is located at 6940 O St, Suite 400 Lincoln NE 68510. For these reasons, the program does not pay for 100% of care that was otherwise eligible. There is a strong, but imperfect, concordance, between the observations housed in the SAS and SQL data. The following information should help you understand who to submit claims to and the requirements you must follow when submitting claims. (refer to the Category tab under Runtime Dependencies), Users must ensure that Microsoft Structured Query Language (SQL) Server is implemented with VA-approved baselines. While all non-VA providers must submit a claim to VA in order to be reimbursed for care, the claim filing deadline depends on the type of claim. VA CCN OptumP.O. Please note that this method providers an indication of the care provided to a Veteran on a single day, rather than in a single encounter, because multiple providers may use the same billing vendor. This is helpful in determining the location of care in inpatient claims in which MDCAREID is missing, and in outpatient claims for hospital-provided services. Available at: http://vaww.virec.research.va.gov/CDW/Overview.htm. [FeeServiceProvided], [Fee]. It can be difficult to identify the specific type of provider associated with Fee Basis care in the currently available national extracts of Fee Basis data. PatientICN is assigned by CDW. Use of this technology is strictly controlled and not available for use within the general population. A valid receipt showing the amount paid for the prescription. Menlo Park, CA. JANESVILLE, WI 53547-4444. or Fax to: TOLL FREE: 844-531-7818 & 248-524-4260 (Utilized for Foreign Claimants) return to top. If you submit a noncompliant claim and/or record, you will receive a letter from us that includes the rejection code and reason for rejection. FBCS is an auditing system which provides instructional prompts designed to interface with the Veterans Information Systems and Technology Architecture (VistA) package to track, report, and analyze fee claim data. If FIPS 140-2 encryption at the application level is not technically possible, FIPS 140-2 compliant full disk encryption (FOE) must be implemented on the hard drive where the DBMS resides. [Patient], [SPatient]. The Fee Basis program or Non-VA Care is health care provided outside VA. NVCC Office coordinates services and payments for Veterans receiving non-VA care for emergent and non-emergent medical care. 2. and constitutes unconditional consent to review and action including (but not limited Appendix D contains information on the primary and foreign keys needed to link the various SQL tables. Values for Fee Purpose of Visit (FPOV), HCFA Payment Type (HCFATYPE), Treatment Code (TRETYPE), Place of Service (PLSER), and Vendor Type (TYPE) appear in Appendix B. There is limited information on the providers associated with Fee Basis care. Researchers must consider whether a missing value means not applicable. For example, many inpatient (INPT) records lack a value for any of the surgery codes (SURG9CD1-SURG9CD5). The Fee Purpose of Visit Code (FPOV) has strong guidance from VA Fee Basis Office and thus may be a more accurate way of categorizing care. All Fee Basis care will be found in the Fee files. You are strongly encouraged to electronically submit claims and required supporting documentation. 2. 3. Office of Accountability & Whistleblower Protection, Training - Exposure - Experience (TEE) Tournament, Outreach, Transition and Economic Development Home, Warrior Training Advancement Course (WARTAC), Staff Appraisal Reviewer (SAR) Information, How to Apply for Nonsupervised Automatic Authority, VALERI (VA Loan Electronic Reporting Interface). Veterans should mail or fax correspondence pertaining to compensation claims to the below location. There may be multiple CPT codes associated with a single encounter. [FeeInpatInvoiceICDDiagnosis], [Dim]. This means the data were placed in the PIT and the claim was not paid through FBCS. more information please visit www.fsc.va.gov. In both SAS and SQL, it can be difficult to determine the provider the Veteran saw for Fee Basis care. This component provides a front end for recognizing claim data through optical character recognition (OCR) software. Quality of Life and Veterans Affairs Appropriations Act of 2006 (Public Law 109-114),the FSC offers a wide range of financial and accounting products and services to both the VA and Other Government Agencies (OGA). Persons interested in studying care provided under the Choice Act may wish to explore the VACAA tables or the FBCS tables at VA Corporate Data Warehouse (CDW). Each record in the pharmacy services (PHR) file represents a single prescription, whether for a medication or a pharmacy supply (e.g., skin cleanser, bathing cloths). Electronic Services Available (EDI): Professional/1. Note that the vendor may represent the hospital, a hospital chain or the entity billing on behalf of the provider. Unauthorized inpatient or outpatient claims must be submitted within 90 days from the date of care. The amount of interest paid on the claim, if any, appears as the variable INTAMT. Passed in 2014 with bipartisan support in Congress, its purpose is to increase Veterans access to health care.1 The Choice Act allows Veterans to receive health care through non-VA providers in the community if they are unable to schedule an appointment at their local VA within 30 days or by a date determined by their provider (wait-time goals), if they reside over 40 miles from a VA facility, or if they face an unusual or excessive burden in travelling to a VA facility.2 Under the Choice Act, ten ($10) billion dollars has been allocated towards Non-VA Medical Care for eligible Veterans through 2017.1 The Fee Basis files contain data for care received through the Choice Act, but in this guide, we do not distinguish for care provided under the Non-VA Medical Care program and that provided under the Choice Act. If this is the case, then it can be assumed that any care provided by the vendor with that VEN13N is actually a hospital with that MDCAREID. A Fee table will contain a record for an ICD-9 code, whereas a DIM table will contain the possible values of that ICD-9 code. Available at: http://www.mssny.org/Documents/Enews/Aug%208%202014/VA%20ProvidersGuide.pdf, 6. Claims processed after March 17, 2022, will be reviewed and aligned with the federal ruling which prohibits secondary payment on emergency care copayments and deductibles. The amount claimed (PAMTCL) appears in the inpatient (INPT) file alone; there is no claimed amount on the outpatient side. Researchers should use PatientICN to link patient data within CDW. For some VEN13N, however, there is more than one MDCAREID. Users must ensure sensitive data is properly protected in compliance with all VA regulations. [FeePrescription] tables. 1. Fee Basis data files contain information regarding both the care the Veteran received and the reimbursement of the care. If it cannot be located in the PTF Main file or DSS NDE for inpatient care, search other inpatient files. Multiple SAS datasets have VENID and VEN13N. In this table, some ancillary data are associated with an inpatient FPOV code but have an outpatient FeeProgramProvided field. This act expands the non-VA care veterans were able to receive before the act was passed. Fact Sheet: Medical Document Submission Requirements for Care Coordination, ADA Dental Claim Form > American Dental Association website. Your monthly premium for Part B may go up 10% for each full 12-month period that you could have had Part B, but didn't sign up for it. As noted above, in SAS, the patient identifier is the SCRSSN; this is unique to each patient across the entire VA. [ICD] table, the latter of which contains a list of all possible ICD-9 codes. Thus, unauthorized care is not unpaid care it is simply not PRE-authorized care. Please contact the referring VAMC for e-fax number. Available at: http://www.blogs.va.gov/VAntage/23201/va-implements-the-first-of-several-veterans-choice-program-eligibility-expansions/. This guide serves as an addendum to any technical documentation supplied by the healthcare clearinghouse when establishing a trading partner agreement. From 1998 to 2014, approximately 50% of claims were paid within 30 days of VA receiving the invoice, and 95% of claims are paid in 200 days or less. If there are multiple providers using the same entity to bill their claims, it will not be possible to disaggregate what type of provider the patient saw (e.g., an internal medicine physician or an infectious disease specialist). See 38 USC 1725 and 1728.). As with the SAS data, the important variables in the SQL data are the AmountPaid and the DisbursedAmount. In both the SAS and the SQL data, there are usually multiple observations per patient encounter. We view the patients insurance data in the VistA file if the claim is flagged as reimbursable in VistA and encompasses the dates on the claim. The National Provider Identifier (NPI) is a unique 10 digit identifier mandated to be used in health claims under the Health Insurance Portability and Accountability Act (HIPAA). The UB-92 equivalent variables would be: facility (after merging in facility name from the FBCS_Facilities table), vistapatkey, and vistaauthkey, respectively. Veterans Health Administration. The same cannot be said for DX2-DX25, however, as additional diagnosis codes are optional. For more information, including information on deductibles and special transports, visit: https://www.va.gov/health-care/get-reimbursed-for-travel-pay/. To enter and activate the submenu links, hit the down arrow. If your claim was submitted to VA, call (877) 881-7618, If your claim was submitted to TriWest, call (877) 226-8749. Review the Where to Send Claims section below to learn where to send claims. As of April 2019, this guidebook is no longer being updated. Many classes of Veterans are eligible for travel payments. The data that is not available is the data element that indicates if it was generated by FBCS or manually entered by the user in FBCS. This is in line with the way VHA Office of Productivity, Efficiency & Staffing (OPES) ascertains ED visit. Much Fee Basis care is pre-authorized prior to the Veteran obtaining care and is thus considered Authorized Care. One way to do this is to concatenate the vendor identifier, the patient identifier, and the visit date. 3. 3. NPI is available within the VA CDW SStaff table. one setting of care (inpatient or outpatient). There is no information available in the SAS data that identifies the actual medication dispensed. This component provides a front end for validation and/or correcting the data that was read from the claim via the OCR module. This technologysupports advanced data encryption methods and role-based access control. For these reasons, VA strongly encourages Veterans to consider important factors, risks and benefits before making any changes to their private health insurance. Note: The last extract occurred in December 2020. All preauthorized claims are then processed through the Fee Basis Claims System (FBCS) at the local facility as well as sent to the payment team. The CDW SharePoint site has a document that lists the purchased care SQL tables, the fields of that they contain, and some sample SQL queries (VA intranet only: https://vaww.cdw.va.gov/metadata/Metadata%20Documents/Forms/AllItems.aspx). a. This component provides a front end for scanning claim forms into a temporary image queue for a given patient. There are three routes for filing claims for authorized care which depend on your status in VAs network and how the care was authorized: All non-urgent and non-emergent care requires authorization from VA in advance. Office of Information and Analytics. Subscribe to our E-newsletter The Service Connection Our monthly newsletter features about important and up-to-date veterans' law news, keeping you informed about the changes that matter. There are nine situations in which Non-VA Medical Care is authorized. VA decisions for specific versions may include + symbols; which denotes that the decision for the version specified also includes versions greater than Additional information appears in a federal regulation, 38 CFR 17.52. Include the 17 alpha-numeric (10 digits + "V" + 6 digits) VA-assigned internal control number (ICN) in the insured's I.D. Emergency care can also be authorized by VA in certain circumstances when the VA is notified within 72 hours. The FeeSpecialtyCodeName contains information on the specialty of the provider seen, such as oncology, chiropractic, pathology, neurosurgery, etc., but is missing much data. There is a CPT field in the inpatient files, but this is always missing; hospitals do not use CPT codes to bill. The DSS Fee Basis Claims System (FBCS) is a web-based claim management system. In addition, VA may place a Veteran in a private or state-run nursing home when a bed in a VA nursing home is unavailable or if the nursing home is distant from the patients residence. In SQL, the patient ID will be the PatientICN or PatientSID, and the admit date is the admission date.. Patient identifiers are also different across SAS and SQL data. For billing questions contact: Health Resource Center No new extracts will occur. Several variables are available for locating care in particular settings. While a researcher could theoretically conduct a Fee Basis analysis using SAS data and then upload these SAS data to CDW and pull in the relevant variables from the SQL Patient domain, this poses some logistical challenges. [FeeServiceProvided] tables. However, we conducted some comparisons for inpatient data. Fee Basis Services. The vendor identity can be found through the FeeVendorSID or the FeeVendorIEN variables in SQL. Please switch auto forms mode to off. This technology can use a VA-preferred database. Some encounters have multiple procedures that are paid as a single encounter; other encounters have multiple procedures and there are separate payments for each procedure. The key that allows for this linkage is the FeeInpatInvoiceSID which is a primary key in the [Fee]. 7. HERC researchers found that claims for the professional component of hospital stays also appeared in the file of claims for outpatient services. There is a deductible of $3 per trip up to a limit of $18 per month. Accessed October 07, 2015. To enter and activate the submenu links, hit the down arrow. VA has set a goal of processing all clean claims within 30 days. Researchers using this tactic also run the risk of not being able to properly link their cohort, as other HERC investigations have revealed an imperfect relationship between SCRSSN and ICN; some SCRSSNs do not have an accompanying PatientICN; some SCRSSNs have multiple PatientICNs. Federal law puts prosthetics into a special payment category that mandates full financial support from VA. As implemented in VA policy, it requires that VA facilities provide all necessary prosthetics, orthotics, and assistive devices (prosthetics) needed by patients. Non-VA providers submit claims for reimbursement to VA. Researchers should pay special attention to reducing duplicates in the pre-2008 data. Table 8 denotes on which CDW servers Fee Basis data are housed. Some Non-VA Medical Care claims are rejected for untimeliness or lack of statutory authority. 2. Claims. March 2015. Optum is a proud partner with the VA through its Community Care Network (CCN). Non-emergency care must be approved before the Veteran seeks care in the community.3 For traditional Non-VA care, a Veterans VA provider will submit a request at the local VA facility for Veteran care provided by Fee Basis. A primary key is a key that is unique for each record. Review the Filing Electronically section above to learn how to file a claim electronically. In FY 2014, the longest length of stay associated with a single nursing home invoice was 31 days. However, Veterans may be responsible for a VA copayment depending on their assigned Priority Group. For dual pension and compensation claims, use the mailing address below for compensation claims. New values may be added over time. For example: services provided at a hospital anticoagulation clinic are billable for facility charges only if the anticoagulation is considered incident to physician services and certain other conditions are met.8. The inpatient data will also need to be linked to the ancillary data, or the data representing the professional services provided to a patient while in the hospital, in order to determine the total cost of the inpatient stay. Researchers can look at the disposition variable as an indicator of transfer between VA and non-VA care. Missingness can vary substantially by year and by file. [ SFeeVendor] table. Payment for these types of care falls under the Non-VA Medical Care program. More information about can be found on their website: https://www.va.gov/communitycare/. Inpatient stays in both SAS and SQL Fee Basis data can denote hospital stays, nursing home stays, or hospice stays. More detailed information about the vendor can be found in the SQL [Dim]. Technologies must be operated and maintained in accordance with Federal and Department security and Using the Non-VA Medical Care data for research requires a basic understanding of laws and regulations that govern it. VSSC provides numerous relevant web reports, data resources, and analytics support, including summary data by facility and VISN and national summary data. However, in Table 4, we present some comparisons to demonstrate the different between SAS and SQL data. Visit the VHA Data Portal for further information on accessing restricted VSSC web reports.
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